Dose escalation of tamoxifen in patients with low endoxifen level

Evidence for therapeutic drug monitoring - The TADE study

Peter Fox, Rosemary L. Balleine, Clara Lee, Bo Gao, Bavanthi Balakrishnar, Alexander M. Menzies, Shang Heng Yeap, Sayed Sahanawaz Ali, Val Gebski, Pamela Provan, Sally Coulter, Christopher Liddle, Rina Hui, Richard Kefford, Jodi Lynch, Mark Wong, Nicholas Wilcken, Howard Gurney*

*Corresponding author for this work

Research output: Contribution to journalArticle

28 Citations (Scopus)

Abstract

Purpose: Endoxifen is the major mediator of tamoxifen effect and endoxifen levels <15 nmol/L may be associated with increased risk of breast cancer recurrence. We increased tamoxifen dose in breast cancer patients with low endoxifen levels and assessed the influence of various parameters on reaching 15 nmol/L and 30 nmol/L endoxifen levels. Experimental Design: Tamoxifen dose was increased in those with endoxifen levels below 30 nmol/L. Toxicity, including hot flash score, was measured. CYP2D6 metabolizer status was classified as ultra-rapid (UM), extensive (EM), intermediate (IM), or poor (PM) based genotype of somatic DNA. Results: Dosage was escalated in 68 of 122 participants. On 20 mg tamoxifen, 24% had endoxifen levels below 15 nmol/L and this reduced to 6% following dose escalation. In over 50% of cases, there was no identified cause for low endoxifen. Low baseline endoxifen level, and not CYP2D6 metabolizer status, independently predicted reaching threshold targets for both the 15 nmol/L and 30 nmol/L targets (P = 0.04 and 0.003 respectively). The 15 nmol/L target was reached in all UM/EM and IM patients, 63% of PM patients, and 58% of those with baseline endoxifen of <10 nmol/L. There was no correlation between hot flash score and genotype or any tamoxifen metabolite level including endoxifen (R = 0.07). Conclusions: Low endoxifen on standard dose tamoxifen was the only independent predictor of failure to achieve potentially therapeutic levels. Trials examining tamoxifen dose escalation and breast cancer outcome should be guided by endoxifen levels alone, without reference to CYP2D6 genotype or presence of hot flashes.

Original languageEnglish
Pages (from-to)3164-3171
Number of pages8
JournalClinical Cancer Research
Volume22
Issue number13
DOIs
Publication statusPublished - 1 Jul 2016

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